Learning the Language of Babies: An Introduction to the World of … the... · 2016-04-26 ·...

Learning the Language of Babies:

An Introduction to the World of

Infant Mental Health Assessments

Tessa Chesher, D.O.

Assistant Professor

Oxley Chair of Child and Adolescent Psychiatry

OU School of Community Medicine

Objectives

To identify areas/fields in which infant mental health knowledge is

important

To recognize the parts of an infant mental health evaluation

To discuss some evidenced based areas of treatment in infant mental

health

To describe training areas and to begin to determine the next level of

training needed for personal infant mental health training goals

Introduction

What we are going to do today:

Define IMH

Look at an overview of attachment

Discuss select IMH assessment measures

Review a few of evidence based treatments

Discuss training in IMH

Part I


Define IMH

Look at an overview of attachment

Infant Mental Health

Ability for the child to:

experience, regulate, and express emotions

form close relationships

Explore the environment

Learn

How does this ability affect development?

Early childhood mental health=health

Why do we need IMH specialists?

Presenting ProblemsAges 0-3

Chronic feeding or sleeping difficulties

Inconsolable “fussiness” or irritability

Incessant crying with little ability to be consoled

Extreme upset when left with another adult

Inability to adapt to new situations

Easily startled or alarmed by routine events

zerotothree.org


Inability to establish relationships with other children or adults

Excessive hitting, biting and pushing of other children

Very withdrawn behavior

Flat affect

zerotothree.org

Presenting Problems

Age 3-6

Compulsive activities (e.g. head banging)

Wild tantrums

Withdrawn, little interest in social interaction

Repeated aggressive or impulsive behavior


Difficulty playing with others

Little or no communication

Lack of language

Loss of earlier developmental achievements

zerotothree.org

Focus of Infant Mental Health

Promotion

Prevention

Treatment

Promotion

For all young children and families

Aimed at maintaining social and emotional well-being

Examples

Public awareness campaign

Home visiting or family support programs

zerotothree.org

Prevention

Children at risk of poor developmental outcomes

Early identification and intervention strategies

Screening

Examples

Focus on improving quality of infant care

Focus on reducing violence in community

Focus in decreasing domestic violence

Treatment

For children and families already showing symptoms

Examples

Therapeutic day care

Psychotherapy for young children with families

Medications

The Pyramid Model

IMH Venues

Therapist

Court

Pediatric Clinics

Child Psychiatry Clinics

Hospital

Preschool

IMH “Need-to-Knows”

Development

Attachment

Development Basics

8-12 weeks

What we see on the outside:

More focused

Better organized

More communicative

More efficient learners

More enjoyable social partners

social smile

Changes in the Brain

Growth of synapses in the cortex

Myelination of visual pathways

Cause enhanced cognitive capacities

Reflected in

Classical and operant conditioning

Habituation

Receptive and expressive communication

Social smiling

Remember longer with less exposure

What Do These Changes Mean?

Babies will anticipate repeated patterns and notice alterations.

If negative alterations

Disruptive effects on regulatory and interactive behaviors

Infants are aware of caregiver’s behavior, which affect baby's

behaviors.

Emotions emerging

Joy

Contentment

Sadness

Anger

Distress

7-9 Months

The Discovery of Intersubjectivity

Baby understands that their own thoughts and feeling can be shared

Baby understands that others have thoughts and feelings

Baby uses other’s affective states to regulate their own emotions and behaviors

7-9 Months

Object permanence

The ability to retain a mental image of an object

Leads to stranger weariness and separation protest

Increased ability to be mobile leads to an increase in exploration

Success leads to an emerging sense of self efficacy, the belief or

expectation that they will be successful in attaining goals

7-9 Months

Onset of focused attachment

Can see attachment patterns of secure and insecure

Why is this important?

The language of the baby

18 to 20 months

An advance in symbolic representation

Increase in language competence

Toddlers can regulate behaviors in service of social goals

Working Models of relationships are developed

Through interactions with their caregivers

Can use patterns of the past to predict the future

Lead to an objective sense of self

Can recognize self in pictures

Emotions develop

Shame

Guilt

Embarrassment

True empathy

24-60 months

Children consolidate, refine and expand these abilities into a sense

of self in relation to others and their place in the world

Attachment Basics

Early Interactions

Loving, supportive

caregivers=positive template of

relationships

Negative caregivers=negative

working model of relationships

Types of Attachment

Secure

Insecure

Avoidant

Ambivalent

Secure Attachment

Through repeated positive experiences with a caregiver, infants develop a

secure attachment to that person.

Infants who are securely attached have learned to trust that other people

will take care of them

Secure Attachment

Children who are securely attached tend to:

have less extreme reactions to stress

be more willing to try new things and to explore independently

be better problem solvers

form better relationships with others

Video Example

Characteristics of Secure Attachment

Children Adults

Able to separate from parent Have trusting, lasting relationships

Seek comfort from parents when

frightened

Tend to have good self-esteem

Return of parents is met with positive

emotions

Comfortable sharing feelings with

friends and partners

Prefers parents to strangers Seek out social support

Insecure Attachment

Infants whose experiences with a caregiver are negative

or unpredictable are more likely to develop an insecure

attachment.

Have learned that adults are not reliable

Do not trust easily.

Insecure Avoidant

Do not orientate to their attachment figure while investigating the

environment.

Very independent of the attachment figure both physically and

emotionally

Do not seek contract with the attachment figure when distressed.

Likely to have a caregiver who is insensitive and rejecting of their

needs .

The attachment figure may withdraw from helping during difficult

tasks and is often unavailable during times of emotional distress .

Behrens, Hesse, & Main, 2007; Ainsworth, 1979; Stevenson-Hinde, & Verschueren, 2002

Insecure: Ambivalent/Resistant

Ambivalent behavioral style towards the attachment figure.

Exhibit clingy and dependent behavior, but will be rejecting of the

attachment figure when they engage in interaction.

Fails to develop any feelings of security from the attachment figure.

Exhibit difficulty moving away from the attachment figure to explore

novel surroundings.

When distressed they are difficult to soothe and are not comforted

by interaction with the attachment figure.

This behavior results from an inconsistent level of response to their

needs from the primary caregiver.

Ainsworth (1970)

Insecure Children

Insecure-ambivalent children

Have a tendency to anxiously but unsuccessfully seek positive peer

interaction

Insecure-avoidant children

Appear aggressive and hostile

may actively repudiate positive peer interaction.

Avoidant Attachment Distress

Are avoidant children truly less distressed?

Measuring the attentional capacity of children, heart rate, or stress

hormone levels

Results?

Behavior Outcomes

Children who are insecurely attached may:

refuse to interact with others

avoid other people

exaggerate distress

show anger, anxiety or fear

Bowlby

“[S]ince much of the development and organization of

[attachment] behavioral systems takes place whilst

the individual is immature, there are plenty of

occasions when an atypical environment can divert

them from developing on an adaptive course.”

Disorganized Attachment

Veered off of the adaptive course

Usually extreme experiences

Maltreatment

Trauma

Abuse

Children or their caregivers have been through a frightening event

DISORGANIZATION

Relationships affect the Brain

Relationship patterns give us a glimpse

into the brain

Attachment affects the right side of the

brain

Connected to autonomic nervous

system

Limbic system

Arousal systems

Brain Changes in Trauma

Emotional and Autonomic Nervous system regulation are blunted in traumatized children

Cortisol (stress hormone) is elevated constantly

Long term exposure = metabolic shutdown

Become detached and withdrawn to protect self

May use dissociation for protection

Limbic system can be permanently affected

What’s the Significance?

Abnormal metabolic and autonomic responses prime the child for lifelong

psychopathology and unhealthy relationships

Extrinsic Risk Factors

Increased in presence of “environmental” risk factors:

Child abuse and neglect

Poverty

Institutional or orphanage care

Marital conflict and partner violence

Parents with drug and alcohol problems

Parents with a history of loss or trauma

What We See in the Child

Social difficulties

role-inappropriate parent-child interactive behavior in middle childhood

peer rejection and poor social adjustment in middle childhood

Aggression

aggressive and disruptive behavior in middle childhood

What We See in the Child

These children can display stereotypies such as hitting themselves

repeatedly or rocking back and forth.

Internalizing problems

low self-esteem

internalizing problems

Dissociative disorders in adolescence

Going Beyond Attachment

Attachment can be Compromised

Extreme rearing conditions

Social neglect

Institutional care

Not insecure attachments – NO ATTACHMENT

Requires pathogenic caregiving

DSM-V Criteria for Reactive Attachment

Disorder of Infancy or Early Childhood

A pattern of markedly disturbed and developmentally inappropriate

attachment behaviors, evident before 5 years of age, in which the child

rarely or minimally turns preferentially to a discriminated attachment figure

for comfort, support, protection and nurturance. The disorder appears as a

consistent pattern of inhibited, emotionally withdrawn behavior in which

the child rarely or minimally directs attachment behaviors towards any

adult caregivers, as manifest by both of the following:

Rarely or minimally seeks comfort when distressed.

Rarely or minimally responds to comfort offered when distressed.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text rev. Washington



A persistent social and emotional disturbance characterized by at

least 2 of the following:

Relative lack of social and emotional responsiveness to others.

Limited positive affect.

Episodes of unexplained irritability, sadness, or fearfulness which are

evident during nonthreatening interactions with adult caregivers.

Does not meet the criteria for Autistic Spectrum Disorder.




Pathogenic care as evidenced by at least one of the following:

Persistent disregard of the child’s basic emotional needs for comfort, stimulation,

and affection (i.e., neglect).

Persistent disregard of the child’s basic physical needs.

Repeated changes of primary caregiver that prevent formation of stable

attachments (e.g., frequent changes in foster care).


How Common is RAD?


DSM-V Criteria for Disinhibited Social

Engagement Disorder

A pattern of behavior in which the child actively approaches and

interacts with unfamiliar adults by exhibiting at least 2 of the

following:

Reduced or absent reticence to approach and interact with unfamiliar

adults.

Overly familiar behavior (verbal or physical violation of culturally

sanctioned social boundaries).

Diminished or absent checking back with adult caregiver after venturing

away, even in unfamiliar settings.

Willingness to go off with an unfamiliar adult with minimal or no hesitation.


DSM-V Criteria for Disinhibited Social

Engagement Disorder

The behavior in A. is not limited to impulsivity as in ADHD but

includes socially disinhibited behavior.

Pathogenic care as evidenced by at least one of the following:

Persistent failure to meet the child’s basic emotional needs for

comfort, stimulation, and affection (i.e., neglect)

Persistent failure to provide for the child’s physical and psychological

safety.

Persistent harsh punishment or other types of grossly inept parenting.

Repeated changes of primary caregiver that limit opportunities to

form stable attachments (e.g., frequent changes in foster care).

Group Work

Whitney is a 30 month old female with a history of being born addicted to methamphetamines. She was taken into DHS custody, and returned to her mother at 4 months after her mother completed a parenting program, a substance abuse workshop, and had consistently negative drug screens.

At 12 months, Whitney was taken into DHS custody after her mother was arrested due to possession of methamphetamines. Whitney had been found alone in an apartment in a dirty diaper, malnourished, sitting on the floor surrounded by drug paraphernalia.

Whitney was placed in an emergency foster home for 1 week before being transferred to a traditional foster home with a foster mother, foster father, and 1 other foster child. This foster family stated that Whitney was sullen and withdrawn and didn’t like to crawl around a great deal. Whitney would stare off into nowhere a great deal of the time. At night, Whitney would cry and have difficulty sleeping. This foster family kept Whitney during the day (no daycare.)

Group Work

After two months, This foster family felt that they did not have the ability to take care of Whitney due to her high needs. No one was sleeping in the house and they felt that something was wrong with Whitney that they couldn’t handle.

Whitney was placed in an emergency foster placement for 3 weeks while a new foster home was found.

At 15 months, Whitney was placed in a therapeutic foster home with no other foster children. She began day care at this time in Educare.

Visitation with Whitney’s mother was re -started as well, and continued for another 12 months until her mother was arrested again with charges of possession and prostitution. During that time, Whitney and her mother went to therapy. Mother eventually relinquished her rights 3 months later.

Whitney’s behavior continued to deteriorate during this 12 months. Foster mother attempted to soothe Whitney, but Whitney pushed away or stared off ignoring her. Whitney acted worse after visitations with her mother – throwing tantrums and not sleeping.

At 30 months, Whitney’s foster mother decided that she would like to adopt Whitney.

Timeline Review

0-4 months: Traditional Foster placement

4-12 months: Biological mother

12 months – 12months 1 week: Emergency foster placement

12months 1 week – 14 months 1 week: Traditional foster placement

14 months 1 week – 15 months: Emergency foster placement

15 months – 30 months: Traditional foster placement on path towards

adoption

Group Work

What are the steps that you would take if you received this case?

What other help would you need to work with this family?

What would you like your role to be?

Do you currently have the knowledge to provide the services that you

would like to provide?

If not, what are your areas of strength and areas to grow?

Next Up:

Attachment Informed Assessment

Questions?

Part II


Discuss select IMH assessment measures

Attachment-informed assessment

Formal Assessment

Assessment in clinical settings

Both can be broken down into

History

observations

http://www.iacapap.org/wp-content/uploads/A.4.-INFANT-ASSESSMENT-072012.pdf

A history of the child’s attachments

Chronological account of the significant attachment figures available to

the child since birth,

Disruptions in care, abandonment or losses, alternate caregivers, neglect of

care and abuse

Availability of the current primary caregiver and contact with other

caregivers

Child’s behavior with each caregiver

Response to changes of caregivers

In older children, relationships with peers and siblings 2 Details and

observations of the infant or child’s current behavior. Of particular interest

in relation to attachment quality and disruptions or disorder are:

Details and observations of the infant

or child’s current behavior

Of particular interest in relation to attachment quality and disruptions or

disorder are:

Help or comfort-seeking behavior

Response to pain or distress

Who do they go to? Do they show distress?

Quality of interaction and ability to use caregiver or another adult for comfort

Ability to explore and play in a new setting,

response to limit setting

nature of the interaction with the clinician.


Observations Provide Information

Parental sensitivity to the child

Child responsiveness to parental care and attention

The fit between them

Child and parent safety

Parents’ capacity to work together to care for the child and the quality of

their relationship.


The relationship and interaction with

the child is affected by:

Immediate contextual factors

Individual aspects and characteristics of the caregiver and child

Events in the past, especially the parents’ experience of being parented.


What parents bring to parenting?

Their psychological and social strengths and resources

Their fantasies of what and who the child will be for them

The history that precedes conception and birth, including their experiences

in their own family and their experiences of being parented

Their expectations of themselves as parents, influenced by their own

experiences of family life

Their psychopathology − the parents’ past and family psychiatric history

and current difficulties including parental substance abuse

Parental age and life stage


Communication between parent and

infant or young child

Contingent

parent is responsive to the child’s cues, rather than intrusive and insensitive

Collaborative

both parties are active participants in the interaction

build or repair their communication together to restore optimal and comfortable

levels of arousal

Emotionally attuned

the parent is able to identify and tune into the child’s emotional state and to

organize their response appropriately.


Developmental Assessments

The Neonatal Behavioral Assessment Scale (NBAS) (Brazelton &

Nugent, 1995) or Newborn Behavioral Observation System (NBO)

Designed to capture the early behavioral responses of infants to their

environment, before their behavior is shaped by parental care.

Assumption is that a baby is both competent and complexly organized

and an active participant in the interaction with caregivers.

Seeks to help understand the infant’s side of the interaction


The Bayley Scales of Infant Development (BSID) (Bayley, 1993)

Children 1-42 months of age,

Child’s language development, problem-solving skills, gross and fine motor

development, attentional capacity, social engagement, affect and emotion,

and the quality of the child’s movement and motor control


The Wechsler Preschool and Primary Scale of Intelligence (WPPSI)

(Wechsler, 2002)

Children older than 30 months

It evaluates children’s verbal comprehension, perception, organization and

processing speed abilities

Gives clinicians a developmental perspective of the child’s intelligence.

The Vineland Adaptive Behavior Scales (Sparrow et al, 1984).

A parent interview

Obtains information on children’s adaptive functioning in real-life situations

covering the domains of daily skills, communication, socialization, motor

functioning and maladaptive behavior.

Assessing Quality of Relationship:

Screeners

Examples:

DC:0-3/DC:0-3R offers measures to assess the quality of the parent-infant

relationship:

Parent-Infant Relationship Global Assessment Scale

Relationship Problems Checklist

Functional Rating Scale for Emotional and Social Functioning Capacities

Measures are directly integrated into the multi-axial scheme.

http://capmh.biomedcentral.com/articles/10.1186/1753-2000-7-17

Parent-Infant Relationship Global

Assessment Scale (PIR-GAS)

DC:0–3R

Similar to the GAF

Scores from 0-100

91–100 Well Adapted

81–90 Adapted

www.zerotothree.org

PIRGAS

21–30 Severely Disordered

11–20 Grossly Impaired

1–10 Documented Maltreatment

Relationship Problem Checklist

The clinician should refer to the listing of descriptive features in the

Diagnostic Classification of Mental Health and Developmental Disorders of

Infancy and Early Childhood, Revised (DC:0-3R) before using the

Relationship Problems Checklist.

Each quality of the parent–infant relationship is described in terms of

characteristic behavioral quality

affective tone

psychological involvement.

The listed features are not intended to be criteria but guidelines for

description.

Relationship Problem Checklist

Relationship qualities

Overinvolved

Under involved

Anxious/Tense

Angry/Hostile

Verbally Abusive

Physically Abusive

Sexually Abusive

Diagnostic Classification of Mental Health and Developmental Disorders of

Infancy and Early Childhood, Revised (DC:0-3R), by ZERO TO THREE

Rating Scale/Questionnaire Comments Reference

Child Behavior Checklist

(CBCL) for 1.5-5 year olds

• Two questionnaires to assess adaptive and maladaptive functioning of 1½ -5 year olds. Rated

by parents, day care providers and teachers

• A recent international project using the CBCL identified consistencies in aggregations of

emotional and behavioral problems in preschoolers across the 24 societies participating in the

study (Ivanova et al, 2010; Rescorla et al, 2011).

• Proprietary

Achenbach

& Rescorla,

2000

Strengths and Difficulties

Questionnaire (SDQ)

• It rates 25 attributes, some positive and other negative. The SDQ has an impact supplement

that helps in the assessment of impairment related to behaviors the child is presenting with.

Parent and teacher versions for three and four year-olds in several languages

• Free of charge

Goodman,

1997

The Ages and Stages

Questionnaire (ASQ-3)

• Developed to identify infants and young children (0 -5) with potential developmental

problems. Five areas are screened: communication, gross motor, fine motor, problem solving,

and personal-social. Completed by parents/caregivers

• Proprietary

Squires &

Bricker, 1999

Other Useful Rating Scales and Questionnaires

Rating

Scale/Questionnaire

Comments Reference

The Ages and Stages

Questionnaire: Social

Emotional (ASQ:SE)

• A culturally versatile tool for clinicians to identify and monitor children at -risk for social,

emotional and behavioral delays. The ASQ-SE rates a child’s development in the

behavioral areas of self-regulation, compliance, communication, adaptive, autonomy,

affect and interaction with people

• Proprietary

Squires et al,

2003

Preschool Age

Assessment (PAPA)

• A structured parent interview for diagnosing psychiatric disorders in preschool children

(two to five years old). Used as a research tool, it can be used in also clinical work.

• Proprietary; formal training required.

Egger &

Angold, 2004

The Parenting Stress Index

– Short Form (PSI-SF)

• Screens for stress in the parent-child relationship, dysfunctional parenting, parental

behavior problems and child adjustment difficulties within the family.

• Available in several languages.

• Proprietary.

Abidin, 1995

Other Useful Rating Scales and Questionnaires

Temperament Scale Examples

Infant Toddler Temperament Tool (IT3)

Activity level

Regularity

Adaptability

Distractibility

Sensitivity

Persistence

Intensity

Approachability

Mood

Carey Temperament Scales

Temperament Assessment Scale for Children

http://ecmhc.org/temperament/index.html

Temperament

Take 5 minutes to fill out your temperament scale

Relationship Components

Internal and External Components

External

recurrent patterns of behavioral interaction.

Internal component

recurrent patterns of subjective experience or internal representation.

Each of these has effects on infant behavior and psychopathology.

Relationship Domains

Parent

Emotional Availability

Warmth/Empathy/Nurturance

Provision of Comfort

Protection

Child

Emotion Regulation

Security/Trust

Comfort Seeking

Vigilance/Self-Protection

Relationship Domains

Parent

Play

Teaching

Structure/ Instrumental

Care/Routines

Limit-Setting/Discipline

Child

Play

Learning/Mastery/Curiosity

Self-Regulation/Routines

Self-Control

Components of Infant-Parent

Relationship

Rbaby IBbaby IBparent Rparent

How do we measure these components?

Assessing Infant-Caregiver

Relationships

Internal Components

Working Model of the Child Interview

External Components

Crowell Play Procedure

Caregiver Interviews

Disorders of Attachment Interview



(WMCI)

Semi-structured; about one hour

Designed to elicit narrative accounts of child and caregiver’s

relationship with the child

May be audiotaped or videotaped for coding purposes

Internal Working Models

Provide rules by which a person perceives self and others and responds

to others in relationships.

Which information is attended to

How information is perceived

Affects engendered by perceptions

Memories evoked

Responses elicited

So What are We Listening For?

Content

Qualitative features

Affective tone

Typology

WMCI Qualitative Features

Richness of perceptions

Coherence

Intensity of involvement

Openness to change

Acceptance

Caregiving sensitivity

Infant difficulty

Irrational fear of loss

WMCI Affective Features

Joy

Pride

Sadness

Disappointment

Fear

Guilt

Shame

Anger

Indifference

WMCI Typologies

Balanced

Full

Restricted

Strained

Key thoughts/words

Full, rich differentiated impression of child

Parent knows this child

Child is valued as an individual

This relationship is important to caregiver

Strengths/weaknesses acknowledged

Emotionally well integrated

WMCI Typologies

Disengaged

Impoverished

Suppressed

Key Thoughts/Words

Emotional distance

Aloofness

Indifference

Descriptions are generic, pat, unelaborated

Normalize

Overly cognitive

Poverty of detail

Little flexibility or sense of discovery

Lack of engrossment in relationship

WMCI Typologies

Distorted

bewildered/confused

distracted

self-involved

role-reversed

Key thoughts/words

Internally inconsistent/incoherent

Engrossment without convincing connection to child

Unable to focus incisively on topic of child

Unsuccessful struggle to feel close to child

insensitive

Video Examples

Let’s compare prenatal and postnatal

responses…

Zeanah,P.

Examples

Describe your impression of your baby’s personality now...

Mother A (Prenatal)

I feel this is a very, very emotional and intense child--very active.

Very verbal and very intense. I’ll know when it’s upset and when it’s

happy. I cried when something beautiful happened at work. I was

sure the baby cried too. The baby kicked and kicked. It felt what I

was feeling.

Zeanah,P.

Examples


Mother A (Postnatal)

Definitely not quiet. He’s got a mind of his own. He’s very alert. If he

had his way, he wouldn’t sleep all day. He likes to stay up and

observe things. Likes human contact, likes a lot of love.

Zeanah,P.

Examples


Father (Prenatal)

Quiet, genuinely warm. Sensitive. Given to deep emotional feelings.

More of a quiet kind of child. Reflective.

Zeanah,P.

Examples


Father (Postnatal)

Alert--he observes things. Not high strung. Sensitive. Kind of an observing

baby. A happy baby. Dependent.

Zeanah,P.

Examples


Adolescent Mother (Prenatal)

He’s smart--he kicks back when I punch him. He’s stubborn--he’ll be like a

pest, a little brat, bugging everybody. Probably a little spoiled. I think he’ll

be the shy type until he knows the person. When he’s around people he

doesn’t know he’ll be quiet.

Zeanah,P.

Examples


Adolescent Mother (Postnatal)

He’s spoiled--he always ends up getting what he wants. I try to discipline him and

tell him , “No!” I try to let him cry himself to sleep. He’s really stubborn. He’s real

alert and he’s strong. He’s playful and stubborn. He’s a lot like his father, who’s

also real stubborn-- always has to get his way.

Zeanah,P.

Disturbances of Attachment Interview

Semistructured interview

Administered by clinicians to caregivers who know the child and the child’s

behavior well.

Interview about things the child does

To understand the child better

Specific probes are designed to elicit more information; they are not

intended to be exhaustive.

This interview takes about 20 minutes

DAI Questions

1) Does s/he have one special adult that s/he prefers? Who is it?

How does s/he show that he prefers that person? Could you

give me a specific example? Are there any other adults that

are special, like this? Who does he prefer most of all?

0 Clearly differentiates among adults

1 Sometimes or somewhat differentiates among adults

2 Rarely or minimally differentiates among adults

DAI Questions

5) How are his/her moods? Is s/he generally happy or is s/he one to be more irritable or sad or serious? Would you say s/he is like that most of the time or some of the time? How much of the time is s/he sad, serious, or irritable.

0 Clearly regulates emotions well with ample positive affect and developmentally expectable levels of irritability and/or sadness.

1 Sometimes or somewhat has difficulty regulating emotions with less positive affect and more irritability and/or sadness than is expected developmentally

2 Rarely or minimally regulates emotions well; instead, has little positive affect and definitely elevated levels of irritability and/or sadness.

DAI Questions

8) Do you think s/he would be willing to go off with a stranger? Why do you think so? Could you give me a specific example? Do you think s/he would do this some of the time or most of the time? Has this way of interacting with strangers changed? Was s/he more/less willing at an earlier age to go off with someone s/he didn’t know?

0 Clearly is not willing to go off readily with relative strangers.

1 Sometimes or somewhat is willing to go off readily with relative strangers.

2 Willing to go off readily with relative strangers.

Observational Dyadic Procedures

Still Face

Strange Situation

Crowell

Nursing Child Assessment Satellite Training

Early Relational Assessment

Hair Combing Task

Newborn Observational Scale/Neonatal Behavioral Assessment Scale

Chapter to Review

Clinical Use of Observational Procedures in Early Childhood Relationship

Assessment

Authors:

Devi Miron

Marva L. Lewis

Charles H. Zeanah, Jr.

Guidelines

Standardize assessment setting and procedures

Include structured and unstructured activities in assessments

Ensure efficiency of assessment procedure

Guidelines

Ensure developmental and cultural appropriateness of the procedure to

the extent possible

Ensure ease of interpretability of observations

Videotape procedures when possible

Standardized assessment

Use same format and same setting for assessment

Administrators

materials

Any variation is from dyad as opposed to assessment

Compare child in different relationships

Un/Structured

Less structured

Less demanding

Less likely to constrain the behavior of the caregiver

i.e. free play

More structured

Can elicit specific behaviors of interest

Looks at individual differences in a standard situation

i.e. separation/reunion, feeding in the NCAST

Efficiency

Observational methods

Provide a “short cut” of learning characteristics of the dyad

Behavior is elicited rather than waiting

i.e. tasks to see anger/frustration

Developmental Appropriateness

Pay attention to age ranges

Look at developmental level as well

Cultural Thoughts

Most procedures are developed for white Americans

One with the most studies across cultures

SSP

Hair brushing procedure

Developed for African Americans

Interpretability

How are you going to use the information from observation?

Research

Coding

Clinical

Observational procedures important

Need training but not formal coding training

Videotape

Important

Patterns

Therapy Uses

Diagnoses

Hair Combing Task

Dr. Lewis

Video tape of hair combing

Can take minutes to hours

Proximity differences found

Close

Moderate

Functional

Look at amount of touch and verbal back and forth

Parent Child Early Relationship

Assessment

Semi structured

2-60months old

4 five minute segments

Feeding segment

Structured task segment

Free play segment

separation-reunion segment

Can assess relationship and guide treatment

Training required in infant development and caregiver infant interactions

NCAST Teaching and Feeding Scale

0-36 months

Used in low and high risk groups

Formal scoring recommended – clinical and research

Used in Nurse Family Partnership

NCAFS (0-12 months) – feeding time behaviors

Feedback given immediately to caregiver

Extensive training needed

Face to Face Still Face Procedure (FFSF)

0-6 months old

Caregiver and infant sit face to face

Step One – play and talk with baby as you usually do

Step Two – episode of “still face”

Separation

Step Three – interact with baby again

Reunion

Can be used to make interpretations about the dyad’s perceptions about

the relationship

Still Face Example

Strange Situation

20 minutes

Secure Attachment Example

Insecure-Resistant Example

Insecure-Avoidant Example


Originally made for 24-54 months, but expanded to 12-60 months


AKA Parent Child Play Procedure

Clinic-based assessment

Requires 30-45 minutes

Combination of more and less structured activities

Videotaped for later review

Limited constraints on behavior

Clinically useful and formally codeable

Crowell Episodes

Free Play

Clean-Up

Bubbles

Structured Teaching Tasks (2-4)

Separation

Reunion

Video Examples

Free Play

Bubble Example

Task Example

Separation

Parent domains

Emotional availability

Nurturance/valuing/empathic responsiveness

Comforting/response to distress

Infant domains

Emotional regulation

Security/trust/self-esteem

Comfort seeking

Separation

Looking at

Stress

Activate attachment system

Self Soothing/Coping Behaviors

Reunion

Parent domains

Emotional availability

Nurturance/valuing/empathic responsiveness

Comforting/response to distress

Infant domains

Emotional regulation

Security/trust/self-esteem

Comfort seeking

Zeanah, 2009

Reunion

How does the dyad reunite?

Caretaker’s response to child’s distress

Congruence between separation and reunion

Resumption of play/exploration

Alterations to the Crowell

Modified Crowell

Free time decreased from 10 to 5 minutes

Tasks decreased to 2

Baby Crowell

6-12months

Newborn Observation Scale/Newborn

Assessment System

Newborn Assessment System

Research based system used for assessment and diagnosis

Newborn observation system

Clinical based for observation and relationship building

Both need formal training – Brazelton Institute

Newborn Observation Scale/Newborn

Assessment System

Ethical and Professional Considerations

Working with babies/young children

Schedule around feeding and sleeping times

Schedule short breaks for snacks or rest

May need to modify or discontinue procedures

Never leave child unmonitored/alone

Be aware of own biases towards parenting practices

Save suggestions for intervention phase

Monitor verbal and non verbal communication

Ethical and Professional Considerations

Videotaping

Extremely helpful for accurate assessment and treatment

Confidentiality and Anonymity

Consent forms

HIPPA

What is the use of the tapes?

Clinical?

Research?

Part 3


Review a few of evidence based treatments

Discuss training in IMH

Infant Treatment Modalities

ABC

PCIT

CBT for Preschoolers

Child Parent Psychotherapy

COS

NIDCAP

California Evidence-Based

Clearinghouse for Child Welfare

The purpose of the CEBC Scientific Rating scale is to evaluate each

practice based on the available research evidence. The topic area expert

assists with identifying practices that meet the following criteria:

Programs that have strong empirical support.

Programs that are in common use in California.

Programs that are being marketed in California.

California Evidence-Based

Clearinghouse for Child Welfare

Ratings:

1. Well-Supported by Research Evidence

2. Supported by Research Evidence

3. Promising Research Evidence

4. Evidence Fails to Demonstrate Effect

5. Concerning Practice

NR. Not able to be Rated on the CEBC Scientific Rating Scale

Attachment and Biobehavioral

Catchup (ABC)

Developed by Mary Dozier, Ph.D.

Caregivers of infants 6 months to 2 years old who have experienced early

adversity

Program Goals:

Increase caregiver nurturance, sensitivity, and delight

Decrease caregiver frightening behaviors

Increase child attachment security and decrease disorganized attachment

Increase child behavioral and biological regulation

http://www.cebc4cw.org/program/attachment -and-biobehavioral-catch-up/

ABC

parent coaches provide parenting training in the parent’s home for weekly

one-hour sessions over a period of 10 weeks.

Sessions use:

Manual

‘‘in the moment’’ feed back about the parent’s interactions with his or her child

Observation of the parent’s behavior

video feedback to highlight parents’ strengths, challenge weaknesses, and

celebrate changes in behaviors.

Rated 1 on the California Evidence-Based Clearinghouse for Child Welfare

scientific rating scale.

http://www.infantcaregiverproject.com/#!about_us/cjg9

Preschool PTSD Treatment (PPT)

Michael Scheeringa, M.D.

12 sessions

3-6 years-old

Theory-driven, manualized protocol based on cognitive-behavioral therapy

(CBT) with modifications for young children.

Similarities with Cognitive-Behavioral Therapy for Sexually Abused Preschool

Children (CBT-SAP) (Cohen and Mannarino, 1996) and Trauma Focused

Coping (TFC) for 8 to 18 year-old children (March and Amaya-Jackson,

1998).


Treatment with young children can be conceptualized as having multiple

ports of entry for the clinician to intervene into the family system (Stern,

1995).

The therapist can target the child’s behavior, the child’s internal

representations of how they feel about themselves and others, the parent’s

internal representations about themselves and their children, the parent-

therapist relationship, and/or the parent-child relationship (Lieberman,

Silverman, & Pawl, 2000)


scientific rating scale.

http://www.infantinstitute.com/MikeSPDF/PPTManual6.pdf


Overview of PPT

Session 1: Psychoeducation, overview

Session 2: Behavior management for defiance module

Session 3: Learn CBT tools – identify feelings.

Session 4: Learn CBT tools – relaxation exercises.

Session 5: Tell the story

Session 6: Easy narrative exposure

Session 7: Medium narrative exposure

Session 8: Medium narrative exposure

Session 9: Worst moment narrative exposure

Session 10: Worst moment narrative exposure

Session 11: Relapse prevention

Session 12: Review/Graduation

Circle Of Security

https://vimeo.com/145329119

Circle of Security- Home Visiting – 4 (COS-HV4):

Increase security of attachment of the child to the parent

Increase parent’s ability to read child’s cues

Increase empathy in the parent for the child

Decrease negative attributions of the parent regarding the child’s motivations

Increase parent’s capacity to self-reflect

Increase parents capacity to pause, reflect, and choose security promoting caregiving behaviors

Increase parent’s capacity to regulate stressful emotional states triggered by the child’s behavior

Rated 3 on the California Evidence-Based Clearinghouse for Child Welfare scientific rating scale.

Circle of Security Parenting (COS-P)

Not Rated on the California Evidence-Based Clearinghouse for Child Welfare scientific rating scale.


Child Parent Psychotherapy (CPP)

Trauma-exposed children aged 0-5

Dyad is the unit of treatment

Trauma and the caregivers’ relational history

How it affect’s the caregiver-child relationship and the child’s developmental trajectory.

Goal: support and strengthen the caregiver-child relationship to restore and protect the child’s mental health.

Treatment also focuses on contextual factors that may affect the caregiver-child relationship

Targets: caregivers’ and children’s maladaptive representations of themselves and each other and interactions and behaviors that interfere with the child’s mental health.

Dyad is guided to create a joint narrative of the psychological traumatic event and identify and address traumatic triggers that generate dysregulated behaviors and affect.

CPP

Focus on the parent-child relationship as the primary target of intervention:

Safety

Affect regulation

Reciprocity in Relationships

Focus on the traumatic event

Continuity of Daily Living

Reflective supervision


scientific rating scale

http://www.cebc4cw.org/program/child-parent-psychotherapy/detailed

Parent Child Interaction Therapy

Shiela Eyeberg

A dyadic behavioral intervention for children for ages 2 – 7 years and their

parents or caregivers

focuses on decreasing externalizing child behavior problems (e.g.,

defiance, aggression), increasing child social skills and cooperation, and

improving the parent-child attachment relationship.

Parents are taught and practice these skills with their child in a playroom

while coached by a therapist.

PCIT is time-unlimited

About 14 weeks, with hour-long weekly sessions.

PCIT Goals

Build close relationships between parents and their children using positive

attention strategies

Help children feel safe and calm by fostering warmth and security between

parents and their children

Increase children’s organizational and play skills

Decrease children’s frustration and anger

Educate parent about ways to teach child without frustration for parent and

child

PCIT Goals

Enhance children’s self-esteem

Improve children’s social skills such as sharing and cooperation

Teach parents how to communicate with young children who have limited

attention spans

Teach parent specific discipline techniques that help children to listen to

instructions and follow directions

Decrease problematic child behaviors by teaching parents to be consistent

and predictable

Help parents develop confidence in managing their children’s behaviors at

home and in public

PCIT


scientific rating scale

The Newborn Individualized Developmental

Care and Assessment Program (NIDCAP)

Program created for the newborn intensive care unit

Observing and then interpreting behaviors of infants within their environment and as reactions to care they receive,

Developmental care plans developed based on these observations and within the context of the infant’s overall goals and efforts at self regulation.

Intensive and special care, neurodevelopmentally supportive

individualized, and family-centered framework

With programs like NIDCAP

Shorter intensive care and overall hospital stay

Better weight gain

Improved behavioral outcomes that endure beyond infancy.

Enhances brain structure and function when measured by EEG and MRI

www.nidcap.org

Reflective Supervision

“Supervision is a context for learning and professional development .” (Zero

to Three)

Three building blocks of reflective supervision

Reflection

Collaboration

Regularity

A Practical Guide to Reflective Supervision

Edited by Sherryl Scott Heller and Linda Gilkerson

Let’s look at Infant Mental

Health Treatment in Action…

Case Example

Training in Infant Mental Health

Depends on what you want to do

Clinical

Assessments and treatments require training and supervision

Research

What’s going on in Oklahoma?

Institute for Building Early Relationships (IBEaR)

State collaborations to further research and education in the area of infant mental health

Oklahoma Association of Infant Mental Health

Affiliate of the World Association of Infant Mental Health

Multi-disciplinary collaboration, education, workforce development, and advocacy for best practices

Child Parent Psychotherapy Training

Safe Babies Court Team

Top rated early childhood educational facilities

Increase in IMH interest in many fields – i.e. medicine

Outside of Oklahoma

World Association of Infant Mental Health (conference every other year)

NTI yearly conference

Trainings, trainings and more trainings

Irving B. Harris Foundation Fellowship

Training is for psychiatrists, psychologist, social workers, and pediatricians

Endorsement Option


For more information regarding Oklahoma

www.okaimh.org


http://www.okaimh.org/

2 Examples of Programs doing IMH

Infant Parent Program

0-3 years old

Partially funded by public mental health system

Target population: children whose well being is threatened by abuse, neglect, or

disorders of attachment

Child Trauma Research Project

3-5 years old

Target population: preschoolers who have witnessed their mothers being

battered by a male partner


Assessments are done in joint sessions with parent and child

Same clinician for assessment and tx

Masters level

Pre/post doc therapists

Variety of disciplines

SW, psychology, nursing, psychiatry

In IMH training program

Supervised by licensed psychologists

1 hour of supervision per week for every case they carry


Topics are introduced as a natural part of conversation

Observations are done naturally as well

1/3 of the cases require formal evaluation of child’s developmental

functioning

Performed by a developmental neuropsychologist


Formal evaluation of child’s developmental functioning

3 appointments 1 week apart, 1.5 hours in length

Session 1

Initial Interview

WMCI

Session 2

Developmentally appropriate toys

Transition from free play to administering an instrument

Instrument

i.e. Bayley, Mullen Scales, Communication and Symbolic Behavior Scales


Session 3: Final session

Feedback session

Only caregivers

May lead to diagnostic formulation necessitating a referral to an early

intervention program


Standardized approach to information gathering

Clinical and research components

Evaluations done by psychologists

4-6 weeks of assessments

Unstructured clinical interviews

Standardized instruments - 9

Semi-structured procedures

2 individual sessions with child (occur during 2 of the mother’s sessions): done by

a different psychologist

4 sessions with mother


Interviews with the mother

Third Assessment

CBCL

IFEEL Pictures

Fourth session

Focuses on mother’s perception of her child

Attachment Q-Sort

Screening Survey of Children’s Exposure to Community Violence – Parent Report Version

Interviews with the child

WPPSI and 15 minute play session with mother

Stories from the MacArthur Story Stem Battery and 15 min play session with mother

Feedback process

Pros/Cons


Allows information to come out organically

Parents get to work at their own pace


Mothers are grateful to be asked about their experiences

Direct questions

Give permission to speak

Addresses shame

Group Work

Whitney is a 30 month old female with a history of being born addicted to methamphetamines. She was taken into DHS custody, and returned to her mother at 4 months after her mother completed a parenting program, a substance abuse workshop, and had consistently negative drug screens.

At 12 months, Whitney was taken into DHS custody after her mother was arrested due to possession of methamphetamines. Whitney had been found alone in an apartment in a dirty diaper, malnourished, sitting on the floor surrounded by drug paraphernalia.

Whitney was placed in an emergency foster home for 1 week before being transferred to a traditional foster home with a foster mother, foster father, and 1 other foster child. This foster family stated that Whitney was sullen and withdrawn and didn’t like to crawl around a great deal. Whitney would stare off into nowhere a great deal of the time. At night, Whitney would cry and have difficulty sleeping. This foster family kept Whitney during the day (no daycare.)

Group Work

After two months, This foster family felt that they did not have the ability to take care of Whitney due to her high needs. No one was sleeping in the house and they felt that something was wrong with Whitney that they couldn’t handle.

Whitney was placed in an emergency foster placement for 3 weeks while a new foster home was found.

At 15 months, Whitney was placed in a therapeutic foster home with no other foster children. She began day care at this time in Educare.

Visitation with Whitney’s mother was re -started as well, and continued for another 12 months until her mother was arrested again with charges of possession and prostitution. During that time, Whitney and her mother went to therapy. Mother eventually relinquished her rights 3 months later.

Whitney’s behavior continued to deteriorate during this 12 months. Foster mother attempted to soothe Whitney, but Whitney pushed away or stared off ignoring her. Whitney acted worse after visitations with her mother – throwing tantrums and not sleeping.

At 30 months, Whitney’s foster mother decided that she would like to adopt Whitney.

Timeline Review

0-4 months: Traditional Foster placement

4-12 months: Biological mother

12 months – 12months 1 week: Emergency foster placement

12months 1 week – 14 months 1 week: Traditional foster placement

14 months 1 week – 15 months: Emergency foster placement

15 months – 30 months: Traditional foster placement on path towards

adoption

Group Work

Have your assessment steps changed for this case?

What other help would you need to work with this family?

What would you like your role to be?

Do you currently have the knowledge to provide the services that you

would like to provide?

If not, what are your areas of strength and areas to grow?

Group Work

How about your workplace?

Would any of these procedures work for you in your current environment?

What is working well?

What are some suggested changes?

What are some ideas for other assessment set ups?

What needs to happen to implement IMH assessments?

Other challenges?

Questions?

Thank You

Thanks to Paula Zeanah, Ph.D. for sharing information for our use today.

Resources

Mares S, Graeff-Martins AS. The clinical assessment of infants, preschoolers and their families. In Rey JM ( ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

Muller, J., et al. Inter-rater reliability and aspects of validity of the parent-infant relationship global assessment scale (PIR-GAS). Child and Adolescent Psychiatry and Mental Health. (2013)7:17.

www.zerotothree.org

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14:245–258.

Lieberman, A., Van Horn, P., Grandison, C., et.al. Mental health assessments of infants, toddlers, and preschoolers in a service program and a treatment outcome research program. Infant Mental Health Journal. 18(2):158-170.

Miron, D., Lewis, M., Zeanah, C. Clinical use of observational procedures in early childhood relationship assessment. In: Zeanah, C. (ed.) Handbook of Infant Mental Health, 3rd edn. New York: Guilford Press, (2009); pp 252-265 .

Zero To Three/National Center for Infants: Diagnostic classification of mental health and developmental disorders of infancy and early childhood: DC: 0-3R. 2005, Washington, DC: Zero To Three.


http://www.zerotothree.org/


Resources

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.


https://prezi.com/_m6cdhkmaxux/the-crowell/


www.nidcap.org

Behrens, Hesse, & Main, 2007; Ainsworth, 1979; Stevenson-Hinde, & Verschueren, 2002.

http://www.brazelton-institute.com/clnbas.html

Lieberman, A., Van Horn, P., Grandison, C., Pekarsky, J. (1997). Mental health assessments of infants, toddlers, and preschoolers in a service program and a treatment outcome research program. Infant Mental Health Journal. 18(2): 158-170.


https://prezi.com/_m6cdhkmaxux/the-crowell/


http://www.nidcap.org/

http://www.brazelton-institute.com/clnbas.html

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